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psnet.ahrq.gov/issue/lack-standard-dosing-methods-contributes-iv-errors
December 07, 2022 - June 10, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest"
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psnet.ahrq.gov/issue/patient-safety-or-0
October 23, 2024 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
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psnet.ahrq.gov/issue/anesthesia-patient-safety-podcast
September 04, 2024 - March 27, 2024
WebM&M Cases
Saline Flush Leads to Acute
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Mismatch of patient identifiers or failure to label the tube leads to test cancellation and caregiver … Examples of Patient Harm Associated with Laboratory Errors
Error identifying an organism leads … Data entry error of a troponin result leads to false diagnosis of myocardial infarction and unnecessary … Mislabeled blood gas specimen leads to delay in results and mismanagement of a patient who is coding. … Miscommunication of a high INR result leads to near fatal bleeding in an outpatient who has received
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www.ahrq.gov/hai/tools/mvp/modules/cusp/build-business-case-fac-guide.html
February 01, 2017 - The cycle begins with generating patient volume, which ultimately leads to earning revenue. … Cost efficiency: process improvement leads to faster medicine delivery with less errors
Cost reduction … malpractice claims or increased capital equipment assets
Intangible improvement: higher staff engagement leads
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psnet.ahrq.gov/node/43788/psn-pdf
February 25, 2015 - Staff responses suggested that insufficient time to manage their workload leads to safety problems,
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digital.ahrq.gov/2018-year-review/research-summary/emerging-innovative-newly-funded-research/engaging-patients-and-families-their-health-care
January 01, 2018 - Care
Research shows that patient and family engagement in healthcare leads
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psnet.ahrq.gov/issue/practitioners-agree-medication-reconciliation-value-frustration-and-difficulties-abound
August 09, 2023 - June 26, 2013
Leaving a discontinued FentaNYL infusion attached to the patient leads
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psnet.ahrq.gov/issue/considering-insulin-pens-routine-hospital-use-consider
May 03, 2023 - May 5, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/voices-frontlines-health-care-safety
May 03, 2023 - June 24, 2020
COVID-19 leads to increased need for dialysis machines.
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psnet.ahrq.gov/issue/iv-vincristine-survey-shows-safety-improvements-needed
March 14, 2023 - June 10, 2018
Failed check system for chemotherapy leads to pharmacist's "no contest"
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digital.ahrq.gov/2020-year-review/research-summary/what-we-fund
January 01, 2020 - Research Program’s funding opportunities are designed to fund research that fills knowledge gaps and leads
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psnet.ahrq.gov/issue/improving-patient-safety-laboratory-medicine
November 16, 2022 - May 21, 2014
When diagnostic testing leads to harm: a new outcomes-based approach for
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psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
February 22, 2023 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - nonsevere penicillin allergy, treatment with cephalosporins without preceding penicillin skin testing leads … Use of non–beta-lactam alternatives in patients reporting penicillin allergies leads to more treatment … National Penicillin Allergy Day (September 28).( 16 )
Take-Home Points
Unverified penicillin allergy leads … January 1, 2019
WebM&M Cases
Lapse in Antibiotics Leads
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psnet.ahrq.gov/node/41027/psn-pdf
September 01, 2016 - This problem leads to alert fatigue on the part of clinicians, but thus far, system
developers have
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psnet.ahrq.gov/node/45751/psn-pdf
January 01, 2019 - The authors suggest that promoting patient safety leads to improved financial outcomes; however, it
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psnet.ahrq.gov/node/45744/psn-pdf
December 19, 2017 - They concluded that hospital size leads to bias when evaluating
hospital performance, disproportionately
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psnet.ahrq.gov/node/47372/psn-pdf
January 01, 2019 - issue/medical-office-survey-patient-safety-culture
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - Although some
studies have suggested that more clinical supervision leads to fewer adverse events, there